Nursing Elites

1. A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical exam?

• A. Start the hepatitis B immunization series.
• B. Teach the patient about hepatitis A immune globulin.
• C. Ask whether the patient has been screened for hepatitis C.
• D. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).

Correct answer: C

Rationale: The correct action for the nurse to include in care when the patient is seen for a routine annual physical exam, according to CDC guidelines, is to ask whether the patient has been screened for hepatitis C. CDC guidelines recommend screening patients born between 1945 and 1965 for hepatitis C due to the high prevalence of undiagnosed cases in this age group. Starting the hepatitis B immunization series is not necessary as the patient already had hepatitis A infection. Teaching the patient about hepatitis A immune globulin is not indicated in this scenario. Testing for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM) is not needed as the patient has already had hepatitis A.

2. A woman presents with bruises on her face and back in various stages of healing. She states, 'sometimes he just gets so angry.' Which of the following statements is most appropriate as a response from the nurse?

• A. Do you mean your boyfriend?
• B. Do you mean your boyfriend?
• C. No one will ever hurt you again.
• D. Tell me more about what happens when he gets angry.

Correct answer: D

Rationale: The most appropriate response from the nurse is to gather more information by asking the client to elaborate on what occurs when the individual in question gets angry. It is essential for the nurse to understand the situation better before taking any action or making assumptions. Option A and B are repetitive and do not encourage further exploration of the situation. Option C offers a false promise and reassurance that the nurse cannot guarantee, which may not be helpful in addressing the client's needs.

3. A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?

• A. Variable decelerations
• B. Late decelerations
• C. Early decelerations
• D. Accelerations

Correct answer: B

Rationale: Late decelerations refer to a pattern where the baby's heart rate decreases during contractions and does not return to normal until after the contraction ends. This is considered a non-reassuring sign as it indicates potential fetal distress. Late decelerations are associated with uteroplacental insufficiency, and immediate medical attention is required. Variable decelerations (Choice A) are abrupt, unpredictable decreases in the fetal heart rate, usually associated with cord compression. Early decelerations (Choice C) are usually benign and mirror the contraction pattern. Accelerations (Choice D) are reassuring signs of fetal well-being, characterized by an increase in the fetal heart rate.

4. A client in the emergency room enters the care area to start an IV. He finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, 'my chest hurts so much!' His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the client?

• A. Bring the IV kit and quickly start an IV
• B. Assess his breathing and provide oxygen, if necessary
• C. Administer medication to control chest pain
• D. Talk with his wife and find out why she is crying

Correct answer: B

Rationale: In the above scenario, the first action of the nurse should be to assess the client's airway and breathing. It is crucial to address respiratory status first, as the client appears to be experiencing difficulty breathing. Providing oxygen if necessary can help support oxygenation and alleviate potential respiratory distress. Administering medication for chest pain or starting an IV can come after ensuring adequate oxygenation. Talking with the client's wife, though important for emotional support, is not the priority when the client's respiratory status needs to be assessed and managed promptly.

5. The discharge planning team is discussing plans for the dismissal of a 16-year-old admitted for complications associated with asthma. The client's mother has not participated in any of the discharge planning processes but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?

• A. The client is an emancipated minor
• B. The mother has to work and is unavailable
• C. The client has a job and a driver's license
• D. The mother does not speak English

Correct answer: A

Rationale: In this scenario, the correct answer is that the client is an emancipated minor. Emancipated minors, even if they are under the age of 18, have the legal right to make decisions about their own healthcare and planning, which may include not wanting their parent involved in the discharge planning process. This status grants them independence from parental involvement in certain situations. The other choices are incorrect because the mother's work schedule, the client's job and possession of a driver's license, and the mother's language proficiency do not inherently prevent her from participating in the discharge planning process, unlike the legal status of being an emancipated minor.

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